Jose Smith/\AIAMBEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCamiamibeachfl.clov
Telephone: 305.673.741 1
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (J) all that apply):
V-1 am a resident of the City of Miami Beach for six months or longer.
Home Address:_2 91 N Smo AE, DR H iA M 113CACA FL• 3,31'4)
L/ I have an ownership interest (for a minimum of six months) in a business established in the
City of Miami Beach (for a minimum of six months).
Name of Business:
T T'(y
Business Address: 94"% d, 5 HOR.0 VA, MtAMI BEAC14, F'L 9.3141
❑ I am a full-time employee of a business (for a minimum of six months) and I am based in an
office or other location of the business that is physically located in Miami Beach (for a
minimum of six months).
Name of Business.-
Business
usiness:
Business Address:
"Ownership Interest" means the ownership of ten percent (109/6) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
"Business" means any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity or business association.
Und nalties of per ury, I declare that I have read the foregoing document and that the facts
ted i it are true
ig e
CJ075� l T 4
Printed Name
Date